Medical Records

Creating Medical Records

Created Medical Records are drafts until finalized either via directly finalizing the MedicalRecord or via the cascading effect of finalizing a MedicalEncounter.

Finalizing Medical Records

Only when a MedicalRecord is finailized will history tracking be enabled on a MedicalRecord so finalizing it is important. There are 2 ways to finalize a MedicalRecord:

1. Finishing a MedicalEncounter will finalize all MedicalRecords associated to it; or
2. A special patch operator finalize: true can be use in the medical-records API's patch method.

Example

curl <base-url>/medical-records/<medical-record-id> \
-X PATCH \
-H "Content-Type: application/json" \
-H "Authorization: Bearer <accessToken>"
-d "{
  "finalize": true,
}"

Medical Records

• Care Plans
• Lab Orders
• Imaging Orders
• Medical Forms
• Prescriptions

Care Plans

A care plan is a type of the MedicalNote record. This record contains the following:

Lab Orders

There are two medical records that comprise the lab test flow: lab-test-order and lab-test-result. It should bear mentioning at this point that there are several Diagnostic entities related to these records. The distinctions are as follows:

• LabTestOrder: When a doctor identifies a need for lab tests, the doctor may produce a written order for the laboratory's reference. This is represented by a LabTestOrder, which is a MedicalRecord of type lab-test-order.
• DiagnosticTest: The doctor may write down one or more tests as part of the written order. Digitally, this is represented by a LabTestOrder containing references to one or more DiagnosticTests. DiagnosticTests in this case are a stand-alone entity that contains information about the actual test to be done. For example, a single LabTestOrder may include the DiagnosticTest for Complete Blood Count and the DiagnosticTest for Urinalysis.
• DiagnosticMeasure: A single DiagnosticTest may in fact be composed of one or more values that are measured as part of the overall test. These are called test measures, and they are represented by another entity called DiagnosticMeasure. A good example here is the Complete Blood Count: it is a single DiagnosticTest, but is composed of several DiagnosticMeasures for Red Blood Cell count, White Blood Cell count, Platelet count, Differential count (eosinophils, basophils, etc.), and so on.
• LabTestResult: A doctor's order for lab tests is fulfilled by a laboratory that will produce results for each test declared in the order. Each test result will also have values for each test measure declared in the test. To manage this, a LabTestResult is used, which is a MedicalRecord of type lab-test-result. A LabTestResult represents the results for a single DiagnosticTest. It contains an array of result values, one for each DiagnosticMeasure associated with that DiagnosticTest. Since LabTestOrders can have more than one DiagnosticTest, it is expected that it can also have more than one LabTestResult.

With these distinctions and flow in mind, the shape of each relevant record can now be understood:

LabTestOrder

LabTestOrderItem

LabTestResult

LabTestResultItem

Imaging Orders

Imaging orders follow the same flow as lab orders. In fact, they share most of the same entities. Here are some crucial differences:

• ImagingTestOrder: Same as LabTestOrder, except this is a MedicalRecord of type imaging-test-order.
• DiagnosticTest: Exactly the same use case as for lab. To distinguish the two use cases, DiagnosticTests have type laboratory if intended for LabTestOrders, and type radiology if intended for ImagingTestOrders.
• DiagnosticMeasure: Unused in practice. Imaging tests produce images, which do not fall under the same test measure model. Instead, each imaging DiagnosticTest expects only a single, qualitative, rich-text report as its result.
• ImagingTestResult: Same as LabTestResult, except this is a MedicalRecord of type imaging-test-result. As hinted above, there is only ever a single result: a qualitative rich-text report.

ImagingTestOrder

ImagingTestOrderItem

ImagingTestResult

ImagingTestResultItem

Medical Forms

Medical forms is the generic medical record object for the following certificates.

• Medical Certificate
• Fitness Certificate
• Health History
• Waiver
• Claims
• Questionnaires
• Generic - The generic version for flexible usage

This record has the following fields:

Here's a sample template data:

{
  "id": "5cc7f95b2d89a34340b79111",
  "type": "med-certificate",
  "template": "I, {doctor_name_0}, after careful examination hereby certify that {patient_name_0} who complained about {patient_complaint_0} was suffering from {patient_diagnosis_0}. \n<br>\nI consider that a period of absence from {custom_text_absence_from_0} from {date_0} to {date_1} is absolutely necessary for the restoration of patient's health.",
  "name": "Medical Certificate Template 2",
  "description": "Template 2. For general purposes (Without Follow-up date)"
}

You'll notice that the template literals contains the keywords enclosed with opening and closing curly braces. These are the tokens to be use for interpolating the data from the values field.

Prescriptions

A Prescription is a medical record with type medication-order. This is the digital representation of the patient's medication order that contains a list of medicines. Medicines are populated in the field called items[Medicine]. The prescription document also contains the following information, clinic info, patient details, and medicines.

Prescription

Medicine